09040079 CITY OF CUPERTINO
BUILDING DIVISION PERMIT A Q*� 3Y 0
BUILDING ADDRESS: PERMIT NO.
20800 HOMESTEAD RD WEST BUILDERS, INC nqn4nn79
OWNER'S NAME: PERMIT ISSUE DATE
eriONE: IC:40R 4T-4 ST SIPE 120 S A CONTROL NO.
(510) 525-9378
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u O p
' LICENSED CONTRACTOR'S DECLARATION Job Description
V 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
In
with Section 70110)of Division 3 of the Business and Professions Code,and my license is
'may intui►fomeandettect /' ahs 5 MODIFY 4 EXISTING UNITS FOR TEMPORARY LAUNDRY
D Eq z License Class , M
Daled 7 /+C _Contractor FAC I LT I E S (3 0 0 0 S Q)
ARCHITEDECLARATION
I understand my plans shall be used as public records
DC6
u. Licensed Professional
-.a
a OW NER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
p O following mason.(Section 7031.5,Business and Professions Code:Any city or county
e,�,f46 which requires a permit to construct,alter,improve,demolish,or repair any structure
4Z- prior to its issuance,also requires the applicant for such permit to file a signed statement
_`e that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
yF- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 4 0 0 0 0
y .» that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than rive hundred dollars(5500). 32609056 . 001A
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Cade:The Contractor's License Law does not apply m an owner of q P
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for ask.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
E]I am exempt under Sec. B&P C for this reason
^•miner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker s Compensation 1 urance c d�plicy number are:
tinier n Policy No.:
CERTIFICATE OF EXEMPTION FROM OR Rs'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less)
I certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Qforthwith comply with such provisions or this permit shall be deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
Fr ham. I hereby affirm that dare is a construction lending agency for the performance of
Ix
the work for which this permit is issued(Sec.3097,Civ.C.)
Wig,A Lender s Name
Z fender's Address
U 0 1 certify that 1 have read this application and sate that the above information is
LL I—, correct I agree to comply with all city and county ordinances and sate laws relating to
O V building construction,and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes
(3r (We)agree to save,indemnify and keep harmless the City of Cupertino against
hFh to liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. 7
r" APPLICANT ERSTANgS ILL PLY ITH ALL NON-POINT Issued by: Date
SOURCE R TIONS.
Re-roofs
Signature A t/Contractor Dale Type of R DOf
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
rode,Section 25532(a)? All roofs;;hall be inspected prior to any roofing material being installed.
❑Yes 10
If a roof i:.installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new m iterials for inspection.
District?
❑Yes GO
I have read the hazardous materials requirements under Chapicr 6.95 of the Califor-
nia Health&SafetyCodc,Sections 25505,25533 and 25534.1 understand that if the building
does not ndy have a tenant,that it is m ponsibilit to notify the occupant of the
require isivhichm ora oecopan . Signature Df Applicant Date
owmerar thoriudagcm D& All roof coverings to be Class'n"or better
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20800 HOMESTEAD RD CONTRACTOR:WEST BUILDERS,INC. PERMIT NO:09040079
OWNER'S NAME: PROMETHEUS 1608 4TH ST STE 120 DATE ISSUED:07/15/2009
l R'S PHONE: 6509313457 BERKELEY,CA 94710 PHONE NO:(510)525-9378
LICENSED CONTRACTOR'S DECLARATION
_ BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic. MECH f— RESIDENTIAL COMMERCIAL
Contractor 9T Date_
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:MODIFY 4 EXISTING UNITS FOR TEMPORARY
(commencing with Section 7000)of Division 3 of the Business&Professions LAUNDRY
Code and that my license is in full force and effect. FACILTIES(3000SQ)
/A(,1,21-S«1 #,.2
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the /ye/ %j
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$40000
permit is issued.
APPLICANT CERTIFICATION APN Number:32609056.001A Occupancy Type:
1 certify that 1 have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-p Qurcc,regulatims..p the Cupertino Municipal Code,Section
9.18.
ignature r--
~ Date 7) ) J ( Issued by: Date:
❑ OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby aff rm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation,
inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code).
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
permit is issued. Additionally,should 1 use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,1 must orizgd
forthwith comply with such provisions or this permit shall be deemed revoked. Dater`' O
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
ify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18• I understand my plans shall be used as public records.
Signature Date Licensed Professional